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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 9520273029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: l of AIAPage of Facility Address: city: Inspection Date: 11 z� . V4vt Lei Cid I Lob g � FA#: ��,/ Program Element: Tank/Container.Information Complete for all sites-with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container Eroduct type, Tank (2820) ❑ Containers (2821) 4o Containers: TA#: __. 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) 0 Containers (2821) *of Containers: TA#: 2 Product Type: Ot Total Capacity: gallons . (per tank or cumulative for containers by product type) Install Date: P Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: t-M] gallons Product Type: w 46 Ma y„ pi I T, (per tank or cumulative for containers'by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821). #of Containers: TA#: 4 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date:. Total Capacity this Page: 9 gallons Total capacity for Site: gallons Comments: LAM) �, A ' S3`0 C. ,j` - 5 i_ EHI]Inspector: Reviewed Date: Entered Date: By initial: By Initial: Q' "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. a "Container means a storage device designed to be moved when full. EHD 2M I fl8li2Jfl8 AST SURVEY FORM